The Liverpool View: Changes in the NHS

Sir Ian Gilmore is Honorary Professor in Clinical Science at the University of Liverpool

“This is a hard blog to write, because it may sound critical of the NHS – an organisation I have served for 42 years and still support passionately.

But it cannot escape the notice of anyone who picks up a newspaper, tunes into a radio station – or indeed has cause to experience it first hand as a patient or relative – that it seems at breaking point.

Breaking point

First you have to discard my rose-tinted spectacles, when everyone got the best care possible. When I was a houseman in 1971, doctor knew best, no-one, least of all the relatives, questioned the wisdom of the treatment provided and patients were the grateful recipients of free care that their parents had had to pay for.

Junior doctors worked 120 hours a week, lived in the hospital, but if there was a lull in the action in the Casualty Department before the 11pm closing time rush, the medical staff would retrench to the ‘mess’ or the pub next door for a quick ‘pint’ themselves.

What has changed? So much that it is difficult to know where to  start.

The population has aged, expectations of the public have risen, so much more is possible. When I was a registrar some conditions like acute leukaemia were uniformly fatal and now they are almost completely curable, but this comes at a cost – both financial and in risky side-effects of powerful drugs.

There has always been, and always will be, human error in delivering care and ‘things go wrong’ but then it was somehow accepted implicitly as part of the lottery of life. Now it is more likely to be under the media spotlight and the subject of legal claims for compensation.

And of course the way the NHS is managed has changed out of all recognition. When I arrived at the Royal Liverpool Hospital as a consultant in 1980, the hospital was run by a few senior consultants and matron, aided by a hospital administrator who took the meeting minutes – no chief executives and tiers of managers;  when we ran out of money a shroud was waved and more arrived by return.

Of course they were ‘happy days’ but that was because the hospital was run to be as convenient as possible for the staff.  Quality of care and outcomes were not words in the medical lexicon, and no-one seemed to question why Mr X’s patients went home the day after their hernia operation whereas Mr Y’s patients all stayed for a fortnight.

So change was needed but change has come along so frequently in the guise of reorganisation that there has never been time to evaluate the results of the previous one, before the next has been upon us. While we are exorted to practice evidence-based medicine, the NHS changes have been largely evidence-free zones.

And now, since April 1^st, we are reeling from the biggest reorganisation since 1948 by a government that promised no structural change.

There are positives – an increased emphasis on quality, outcomes and clinical leadership. But on the other side of the equation is the commissioning conundrum – do the huge costs of commissioning services across a purchaser–provider separation really bring savings, efficiencies and improved outcomes?

The chances are that we shall never know as the pieces of the jigsaw will be shuffled again before long.

Most important asset

But what we must always remember is what really matters – what happens to the patient at the point where front-line staff deliver care, whether it be a complex operation or handing out a cup of tea and some words of sympathy.

Our staff are our most important asset, they don’t want to give poor or dangerous care, but if we don’t keep a careful eye on how system changes affect the day-to-day motivation and behaviour of doctors and nurses, there will be more disasters for patients and families like those experienced in mid-Staffordshire.

We simply can’t allow that to happen again.”